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Aims: Transcatheter mitral valve replacement (TMVR) is an emerging technology with the potential to treat patients with severe mitral regurgitation at excessive risk for surgical mitral valve surgery. Multimodality imaging of the mitral valvular complex and surrounding structures will be an important component for patient selection for TMVR. Our aim was to describe and evaluate a systematic multi-slice computed tomography (MSCT) image analysis methodology that provides measurements relevant for transcatheter mitral valve replacement., Methods and Results: A systematic step-by-step measurement methodology is described for structures of the mitral valvular complex including: the mitral valve annulus, left ventricle, left atrium, papillary muscles and left ventricular outflow tract. To evaluate reproducibility, two observers applied this methodology to a retrospective series of 49 cardiac MSCT scans in patients with heart failure and significant mitral regurgitation. For each of 25 geometrical metrics, we evaluated inter-observer difference and intra-class correlation. The inter-observer difference was below 10% and the intra-class correlation was above 0.81 for measurements of critical importance in the sizing of TMVR devices: the mitral valve annulus diameters, area, perimeter, the inter-trigone distance, and the aorto-mitral angle., Conclusions: MSCT can provide measurements that are important for patient selection and sizing of TMVR devices. These measurements have excellent inter-observer reproducibility in patients with functional mitral regurgitation.

Aims: Transcatheter mitral valve replacement (TMVR) is an emerging technology with the potential to treat patients with mitral regurgitation at excessive risk for mitral valve surgery. Geometrical measurements of the mitral valvular complex may have implications for the design of TMVR devices and for patient selection. This study sought to quantify the dynamic geometry of the mitral valvular complex in patients with significant functional mitral regurgitation (FMR) using multi-slice computed tomography (MSCT)., Methods and Results: MSCT images were acquired in 32 patients with symptomatic, significant FMR. Two independent observers analysed image sets using a dedicated software package and a standard measurement methodology. In patients with FMR, the mean mitral annulus intercommissural and aorto-mural diameters were, respectively, 41.5±5.2 mm and 38.7±5.9 mm in systole, and were 41.5±4.4 mm and 40.0±4.7 mm in diastole. In patients without MR, the diameters were, respectively, 33.6±5.1 mm and 28.8±8.0 mm in systole, and 36.2±4.5 mm and 31.6±7.9 mm in diastole. The obstacle-free zone below the mitral annulus averaged more than 20.0 mm and varied by less than 1 mm between systole and diastole, which is not statistically significant. The aorto-mitral angle was 129.7±10.5° in systole and 131.0±9.4° in diastole., Conclusions: The mitral annulus is larger in dimension, more circular, and less dynamic in patients with FMR. The obstacle-free zone below the mitral annulus is relatively constant during the cardiac cycle. Measurements of the mitral valvular apparatus vary considerably between patients, which suggests that tridimensional imaging will play an important role in the sizing of TMVR devices.

Aims: A comprehensive description of transcatheter heart valve (THV) failure has not been performed. We undertook a systematic review to investigate the aetiology, diagnosis, management, and outcomes of THV failure., Methods and Results: The systematic review was performed in accordance with the PRISMA guidelines using EMBASE, MEDLINE, and Scopus. Between December 2002 and March 2014, 70 publications reported 87 individual cases of transcatheter aortic valve implantation (TAVI) failure. Similar to surgical bioprosthetic heart valve failure, we observed cases of prosthetic valve endocarditis (PVE) (n = 34), structural valve failure (n = 13), and THV thrombosis (n = 15). The microbiological profile of THV PVE was similar to surgical PVE, though one-quarter had satellite mitral valve endocarditis, and surgical intervention was required in 40% (75% survival). Structural valve failure occurred most frequently due to leaflet calcification and was predominantly treated by redo-THV (60%). Transcatheter heart valve thrombosis occurred at a mean 9 ± 7 months post-implantation and was successfully treated by prolonged anticoagulation in three-quarters of cases. Two novel causes of THV failure were identified: late THV embolization (n = 18); and THV compression (n = 7) following cardiopulmonary resuscitation (CPR). These failure modes have not been reported in the surgical literature. Potential risk factors for late THV embolization include low prosthesis implantation, THV undersizing/underexpansion, bicuspid, and non-calcified anatomy. Transcatheter heart valve embolization mandated surgery in 80% of patients. Transcatheter heart valve compression was noted at post-mortem in most cases., Conclusion: Transcatheter heart valves are susceptible to failure modes typical to those of surgical bioprostheses and unique to their specific design. Transcatheter heart valve compression and late embolization represent complications previously unreported in the surgical literature., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2014. For permissions please email: journals.permissions@oup.com.)

Background: Limited information exists describing the results of transcatheter aortic valve (TAV) replacement in patients with bicuspid aortic valve (BAV) disease (TAV-in-BAV)., Objectives: This study sought to evaluate clinical outcomes of a large cohort of patients undergoing TAV-in-BAV., Methods: We retrospectively collected baseline characteristics, procedural data, and clinical follow-up findings from 12 centers in Europe and Canada that had performed TAV-in-BAV., Results: A total of 139 patients underwent TAV-in-BAV with the balloon-expandable transcatheter heart valve (THV) (n = 48) or self-expandable THV (n = 91) systems. Patient mean age and Society of Thoracic Surgeons predicted risk of mortality scores were 78.0 ± 8.9 years and 4.9 ± 3.4%, respectively. BAV stenosis occurred in 65.5%, regurgitation in 0.7%, and mixed disease in 33.8% of patients. Incidence of type 0 BAV was 26.7%; type 1 BAV was 68.3%; and type 2 BAV was 5.0%. Multislice computed tomography (MSCT)-based TAV sizing was used in 63.5% of patients (77.1% balloon-expandable THV vs. 56.0% self-expandable THV, p = 0.02). Procedural mortality was 3.6%, with TAV embolization in 2.2% and conversion to surgery in 2.2%. The mean aortic gradient decreased from 48.7 ± 16.5 mm Hg to 11.4 ± 9.9 mm Hg (p < 0.0001). Post-implantation aortic regurgitation (AR) grade ≥ 2 occurred in 28.4% (19.6% balloon-expandable THV vs. 32.2% self-expandable THV, p = 0.11) but was prevalent in only 17.4% when MSCT-based TAV sizing was performed (16.7% balloon-expandable THV vs. 17.6% self-expandable THV, p = 0.99). MSCT sizing was associated with reduced AR on multivariate analysis (odds ratio [OR]: 0.19, 95% confidence intervals [CI]: 0.08 to 0.45; p < 0.0001). Thirty-day device safety, success, and efficacy were noted in 79.1%, 89.9%, and 84.9% of patients, respectively. One-year mortality was 17.5%. Major vascular complications were associated with increased 1-year mortality (OR: 5.66, 95% CI: 1.21 to 26.43; p = 0.03)., Conclusions: TAV-in-BAV is feasible with encouraging short- and intermediate-term clinical outcomes. Importantly, a high incidence of post-implantation AR is observed, which appears to be mitigated by MSCT-based TAV sizing. Given the suboptimal echocardiographic results, further study is required to evaluate long-term efficacy., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to assess the differential adherence to transcatheter heart valve (THV)-oversizing principles between transesophageal echocardiography (TEE) and multislice computed tomography (CT) and its impact on the incidence of paravalvular leak (PVL)., Background: CT has emerged as an alternative to 2-dimensional TEE for THV sizing., Methods: In our early experience, TEE-derived aortic annular diameters determined THV size selection. CT datasets originally obtained for vascular screening were retrospectively interrogated to determine CT-derived annular diameters. Annular dimensions and expected THV oversizing were compared between TEE and CT. The incidence of PVL was correlated to TEE- and CT-based oversizing calculations., Results: Using TEE-derived annulus measurements, 157 patients underwent CoreValve implantation (23 mm: n = 66; 29 mm: n = 91). The estimated THV oversizing on the basis of TEE was 20.1 ± 8.2%. Retrospective CT analysis yielded larger annular diameters than TEE (p < 0.0001). When these CT diameters were used to recalculate the percentage of oversizing achieved with the TEE-selected CoreValve, the actual THV oversizing was only 10.4 ± 7.8%. Consequently, CT analysis suggested that up to 50% of patients received an inappropriate CoreValve size. When CT-based sizing criteria were satisfied, the incidence of PVL was 21% lower than that with echocardiography (14% vs. 35%; p = 0.003). Adherence to CT-based oversizing was independently associated with a reduced incidence of PVL (odds ratio 0.36; 95% confidence interval: 0.14 to 0.90; p = 0.029); adherence to TEE-based sizing was not., Conclusions: Retrospective CT-based annular analysis revealed that CoreValve size selection by TEE was incorrect in 50% of patients. The percentage of oversizing with CT was one-half of that calculated with TEE resulting in the majority of patients receiving a THV that was too small., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Surgery for aortic root aneurysm without valve stenosis is increasingly being transformed from the Bentall procedure to valve-sparing aortic root remodelling or reimplantation. In this report, a new repair option is explored, with full functional 'restoration' of the aortic root complex using a geometric annuloplasty ring, leaflet repair, and sinus/ascending aortic replacement with a Valsalva graft., Methods: The geometric annuloplasty ring restores elliptical annular shape and size in patients with tri-leaflet aortic insufficiency (AI). The ring mounts the three valve commissures on 10° outwardly flaring posts, and facilitates required leaflet procedures. In clinical application, the device has been effective in achieving stable AI reduction with low valve gradients. In this report, 6 patients with aortic root aneurysms and moderate/severe AI were managed with valve repair using the annuloplasty device and leaflet reconstruction, and then concomitant sinus and ascending aortic graft replacement with coronary implantation., Results: In the 6 initial root aneurysm patients, there were no in-hospital mortalities, procedural conversions, or valve-related complications. Preoperative AI grade was 2-4 and fell to 0-1 postoperatively. Post-repair mean systolic gradients ranged from 7 to 12 mmHg, and all patients had stable intermediate-term valve function., Conclusions: Aortic root restoration using a geometric annuloplasty ring and Valsalva graft may be the most physiological method of aortic valve repair and root replacement. Even with severe leaflet derangements, valve sparing can be achieved with good competence and potentially stable long-term results. This technique could assist in extending valve sparing into most categories of aortic root disease., Clinical Trials: Patients were managed as part of a Phase I (ClinicalTrials.gov Identifier: NCT01400841), supported by BioStable Science and Engineering (BSE), Austin, TX, USA; www.biostable-s-e.com.

Aims: To evaluate the outcomes of mitral valve surgery in octogenarians with severe symptomatic mitral regurgitation (MR)., Methods and Results: We performed a systematic review and meta-analysis of data on octogenarians who underwent mitral valve replacement (MVR) or mitral valve repair (MVRpr). Our search yielded 16 retrospective studies. Using Bayesian hierarchical models, we estimated the pooled proportion of 30-day mortality, postoperative stroke, and long-term survival. The pooled proportion of 30-day postoperative mortality was 13% following MVR (10 studies, 3,105 patients, 95% credible interval [CI] 9-18%), and 7% following MVRpr (six studies, 2,642 patients, 95% CI: 3-12%). Furthermore, pooled proportions of postoperative stroke were 4% (six studies, 2,945 patients, 95% CI: 3-7%) and 3% (three studies, 348 patients, 95% CI: 1-8%) for patients undergoing MVR and MVRpr, respectively. Pooled survival rates at one and five years following MVR (four studies, 250 patients) were 67% (95% CI: 50-80%) and 29% (95% CI: 16-47%), and following MVRpr (three studies, 333 patients) were 69% (95% CI: 50-83%) and 23% (95% CI: 12-39%), respectively., Conclusions: Surgical treatment of MR in octogenarians is associated with high perioperative mortality and poor long-term survival with an uncertain benefit on quality of life. These data highlight the importance of patient selection for operative intervention and suggest that future transcatheter mitral valve therapies such as transcatheter mitral valve repair (TMVr) and/or transcatheter mitral valve implantation (TMVI), may provide an alternative therapeutic approach in selected high-risk elderly patients.

Objective: The aim of the present study was to assess the efficacy and mid- to long-term results of different cerebral protection techniques in the treatment of acute type A aortic dissection., Methods: Between April 1987 and January 2011, 329 patients (220 male patients; median age, 60 years; range, 16-87) with type A aortic dissection underwent replacement of the ascending aorta or aortic arch with an open distal anastomosis. Either hypothermic circulatory arrest alone at 18 °C (n = 116; 35%) or combined with retrograde cerebral perfusion (n = 122; 37%) or antegrade cerebral perfusion at 25 °C (n = 91; 28%) was used., Results: The median circulatory arrest time was 30 minutes (range, 12-92). The overall 30-day mortality was 19% (62 of 329). The 30-day mortality stratified by group was 26% (30 patients) in the hypothermic circulatory arrest group, 16% in the retrograde cerebral perfusion group (20 patients), and 13% (12 patients) in the antegrade cerebral perfusion group (P = .047). Permanent neurologic dysfunction occurred in 53 patients (16%), with statistically significant differences among the 3 groups (23% for hypothermic circulatory arrest, 12% for retrograde cerebral perfusion, and 12% for antegrade cerebral perfusion; P = .033). Univariate analysis showed a significant effect of the brain protection strategy on 30-day mortality and neurologic outcome. Multivariate analysis revealed preoperative hemodynamic instability, preoperative resuscitation, age, and operative year as independent predictors of 30-day mortality. Regarding permanent neurologic dysfunction, the multivariate analysis could not identify any independent predictors. Kaplan-Meier analyses revealed statistically significant differences among the 3 groups with a 1-, 3-, and 5-year survival rate of 84%, 79%, and 77% with antegrade cerebral perfusion, 75%, 72%, and 66% with retrograde cerebral perfusion, and 66%, 62%, and 60% with hypothermic circulatory arrest alone., Conclusions: Patients in the antegrade cerebral perfusion group had the best short- and long-term survival rates. However, during the study period, several significant improvements in the treatment of patients with type A aortic dissection were achieved; therefore, independent predictors of mortality and permanent neurologic dysfunction were difficult to identify., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Histological response of colorectal cancer liver metastases to chemotherapy may be graded based on the extent of tumor regression. The knowledge about the effect of bevacizumab, if given in addition to fluoropyrimidines and oxaliplatin, on tumor regression and its consequences on clinical outcome is limited., Materials and Methods: Resected liver metastases from patients of 2 prospective nonrandomized trials (fluoropyrimidines and oxaliplatin +/- bevacizumab) were analyzed retrospectively. Histological response was analyzed according to an established tumor regression grading for colorectal cancer liver metastases. Tumor regression grades (TRGs) were correlated to progression-free and overall survival., Results: Bevacizumab improved tumor regression to chemotherapy significantly. Improvement in histological response was translated into a significant prolongation of progression-free and overall survival., Conclusions: Classifying histological response based on tumor regression grades qualifies to predict the outcome of patients with colorectal cancer liver metastases. Tumor regression grading provides a standardized pathological response evaluation, against which radiologic response on chemotherapy including biologicals can be prospectively evaluated.

Purpose: The aim of this study was to evaluate the efficacy and safety of thoracic endovascular aortic repair with a newly designed Relay thoracic stent graft (Bolton Medical, Sunrise, FL)., Description: Between 2005 and 2007, 22 patients (71.8 +/- 8.5) received 24 stent grafts. Indications were aneurysms (n = 13), penetrating atherosclerotic ulcers (n = 7), and dissections (n = 2). Due to the proximity of the lesions to the aortic arch, rerouting procedures (ie, subclavian transposition [n = 1], double transposition [n = 12], and total arch rerouting [n = 6] were performed pre-interventionally; three patients did not undergo rerouting). All patients were followed-up with a computed tomographic scan of the entire aorta at discharge, 3 months, 6 months, and annually thereafter (mean follow-up, 13 months)., Evaluation: Primary technical success was obtained in 20 of 22 patients, with one persisting type I endoleak and one asymptomatic type II endoleak. One patient died due to malignant arrhythmia 3 days after stent-graft placement. During follow-up, 1 nonaortic related death was observed. No additional endoleaks were observed. Finally, all supra-aortic rerouting procedures remained patent., Conclusions: In the treatment of degenerative disease of the descending aorta and the aortic arch, the Bolton Relay stent graft offers acceptable efficacy and safety in short-term follow-up.

Background: The purpose of this study is to compare costs of conventional surgical therapy with costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms., Methods: Fifteen patients undergoing either conventional surgical therapy or endovascular stent-graft placement of thoracic aortic aneurysms were analyzed. A catalog of costs was then created for both procedures and this catalog was applied individually to each patient., Results: Total costs of the service provision of endovascular stent-graft placement including anesthesia were 38.220.98 euros considering 1.7 stent-grafts per patient and including 5900.00 euros (Euros) for days of care. In conventional surgical therapy, adding the costs of the service provision of left heart catheterization, conventional surgical therapy including anesthesia, as well as intraoperative echocardiography a sum of 19.534.12 euros was calculated. Days of care accounted for 31.230.00 euros and total costs of 50.764.12 euros were calculated. The difference between total costs of the two procedures was 12.543.14 euros., Conclusions: Costs of endovascular stent-graft placement in patients with thoracic aortic aneurysms compare favorably with conventional surgical therapy, revealing a cost benefit of 24.7%. Higher procedural costs are outweighed by a lower number of days of care. Nevertheless, aneurysm-related secondary endovascular or surgical procedures may balance the benefit of endovascular therapy. Which strategy to choose, conventional or endovascular, should remain to be based on age, comorbidity, and technical feasibility.

Background: Supra-aortic transpositions in various extents followed by endovascular stent graft placement are now an established tool in the treatment of various pathologies affecting the aortic arch. Results remain to be determined., Methods: From 1996 through 2007, 73 patients (median age, 71 years) presented with aortic arch pathology (atherosclerotic aneurysms, n = 42; type B dissections, n = 9; penetrating ulcers, n = 17; traumatic lesions, n = 2; aneurysms based on prior surgery for aortic coarctation, n = 3). Strategy for distal arch disease was subclavian-to-carotid transposition (n = 24) or autologous double-vessel transposition through upper hemisternotomy (n = 36). For entire arch disease, total supra-aortic rerouting with a reversed bifurcated prosthesis was applied (n = 13). Endovascular stent graft placement was performed metachronously., Results: In-hospital mortality was 6.8% (n = 5). Persistent early type I and III endoleak rate was 9.6%. Persistent late type I and III endoleak rate was 5.5%. Overall actuarial survival was 90%, 86%, and 72% at 1, 3, and 5 years. Mean follow-up is 37 months (range, 1 to 120). Early and late endoleak formation was independently predicted by the number of prostheses (early odds ratio [OR] 0.210, p = 0.0003; late OR 0.216, p = 0.012), whereas logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) reached borderline significance regarding late endoleaks (OR 2.1, p = 0.095). An earlier year of implantation reached borderline significance predicting survival (OR 1.9, p = 0.062). Furthermore, survival was independently predicted by higher logistic EuroSCORE levels (OR 1.8, p = 0.020). Interestingly, type of arch rerouting did not influence endoleak formation and survival (OR 0.9, p = 0.812)., Conclusions: Results after supra-aortic transpositions in various extents followed by endovascular stent graft placement for the treatment of various pathology affecting the aortic arch are promising. Endoleak formation is directly related to the number of prostheses and may be reduced by longer devices. Each type of arch rerouting, irrespective of extent, has turned out to be effective. Therefore, extended applications of these combined treatment strategies substantially augment the therapeutic options.

Background: The purpose of this study was to address a previously not described mechanism underlying intramural hematoma (IMH) of the entire thoracic aorta and to test the hypothesis whether endovascular stent graft placement in this particular mechanism could be beneficial., Methods: Within a 5-year period, we treated 8 patients with IMH affecting the entire thoracic aorta. The presumed site of initial plaque rupture was chosen as target for endovascular stent graft placement., Results: In all patients, a small atherosclerotic plaque at the free lateral wall or at the concavity of the distal aortic arch could be identified as initial site of IMH. Endovascular stent graft placement was performed successfully in all patients. By covering the suspected primary lesion, resorption of IMH especially within the ascending aorta could be achieved. Mean follow-up is 16 months (range, 1 to 25)., Conclusions: Plaque rupture may be identified as the cause of IMH in a previously unrecognized subgroup of patients. If at the convexity of the distal arch, supra-aortic branches prevent retrograde extension toward the ascending aorta. If at the free lateral wall or at the concavity, IMH may affect the entire thoracic aorta, owing to the lack of the natural barrier of the supra-aortic branches. Endovascular stent graft placement of this plaque-associated IMH may be more effective and less invasive than conventional surgery to treat the entire thoracic aortic disease.

We report 2 patients who were referred for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta) that was causing abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement and are free of symptoms, with regular findings at 6-month follow-up completion computed tomography scan.

Background: The performance of endovascular stent-graft placement in patients suffering from aneurysms involving the descending aorta originating from chronic type B dissections is unclear., Methods: Within a 2-year period, we treated 6 patients with this pathology. Four patients required extension of the proximal landing zone (autologous double transposition, n = 2; subclavian-to-carotid artery transposition, n = 2) before stent-graft placement., Results: Supra-aortic rerouting procedures and endovascular stent-graft placement were performed successfully in all patients. Closure of the primary entry tear, full expansion of the stent-graft, and eventually, thrombosis of the false lumen was achieved in 5 patients. In 1 patient with a short proximal landing zone, a persisting type Ia endoleak was observed. In all patients with successful primary entry closure, a reduction in aneurysm diameter occurred. Mean follow-up is 16 months (range, 4 to 25)., Conclusions: Endovascular stent-graft placement of aneurysms involving the descending aorta originating from chronic type B dissections may serve as a valuable treatment option in this complex pathology. The chronic dissection membrane can be successfully compressed against large areas of the native aortic wall. A sufficient proximal landing zone is mandatory for early and late success.